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Pain management in augmentation mammaplasty: a randomized, comparative study of the use of a continuous infusion versus self-administration intermittent bolus of a local anesthetic
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Pain Management in Augmentation Mammaplasty: A Randomized, Comparative Study of the Use of a Continuous Infusion Versus Self-Administration Intermittent Bolus of a Local Anesthetic Peter T. Pacik, MD Dr. Pacik is in private practice in Manchester, NH.
Background: Indwelling catheters for pain control after augmentation mammaplasty appear to be safe and effective. However, little is known regarding the comparison of continuous flow to intermittent bolus anesthetics. Objective: A prospective, randomized study was developed to compare these 2 systems. Methods: Forty-one patients were divided into 2 groups. All patients used the On-Q (I-Flow Corp, Lake Forest, CA) continuous infusion pump system (2 mL per hour) in 1 breast. Group 1 consisted of 20 patients who, in the opposite breast, were permitted to bolus themselves with 20 mL of 0.25% bupivacaine HCl with 1:400,000 epinephrine (Sensorcaine; Astra Zeneca, Wilmington, DE) as needed, every 6 hours for a maximum of 2 doses. Group 2 consisted of 21 patients who were requested to instill 10 mL of 0.25% bupivacaine with 1:400,000 epinephrine every 4 hours (total 4 instillations) regardless of need (except during sleep). Results with regard to effectiveness and patient preference in both groups were assessed. All patients were asked to avoid any additional analgesics or narcotics for 30 to 60 minutes after self-administration in order to record an unbiased self-assessment response to the instillation of local anesthesia. All patients were seen the day after surgery and given an additional 20 mL of bupivacaine on the self-administration side before implant mobility exercises. Results: In group 1, 10 patients preferred the continuous On-Q infusion, 9 patients preferred the self-administration bolus, and 1 patient who had no pain on either side was undecided. Among patients in this group, 24-hour pain scores were similar. In group 2, 13 patients preferred the continuous On-Q infusion, 5 patients preferred self-administration, and 3 patients were undecided. Pain scores in group 2 were lower for On-Q. An unexpected finding was that after unilateral self-administration, 20 of 41 patients (42%) noted bilateral reduction of pain. By day 3, 33 of 41 patients (80%) used no narcotics. There were no complications associated with either device. Conclusions: After augmentation mammaplasty, both indwelling catheters using continuous flow and intermittent bolus anesthesia as needed are effective in controlling postoperative pain. Continuous flow maintains a steady state of pain control without patient intervention. Self-administration allows patients to have a more active role if they have pain and is an effective low-cost alternative to a commercial pain pump. These conclusions are supported by a review of the literature and by our own experience with more than 380 consecutive patients. (Aesthetic Surg J 2004;24:523-530.)
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ndwelling catheters are used to introduce local anesthesia in order to control postoperative pain in a variety of surgical specialties. However, the use of this type of pain control in augmentation mammaplasty procedures is in its infancy. Little is known as to whether intermittent bolus anesthesia or continuous flow is more effective. Patients undergoing submuscular augmentation mammaplasty may experience significant postoperative pain and discomfort. The use of narcotics and muscle
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relaxants has not offered complete relief. In response to this problem, we conducted an initial trial of 200 patients, over a 5-year period (1996-2001), treated with periodic instillations of bupivacaine through indwelling catheters placed in the subpectoral pocket. We determined that local anesthetics delivered in this manner are both safe and effective.1,2 At the time the study was initiated, continuous flow systems were generally unavailable. A number of continuous flow “pain pumps” are now on the market, but
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Table 1. Indwelling catheter technique • The needle of a scalp vein catheter (Exel scalp vein set, Exelint International, Los Angeles, CA) is cut off and discarded. • The full length of the catheter (usually 8-Fr) is placed first, posterior to the implant. • The cut tip is placed superiorly. The luer lock end exits at the lateral margin of incision, held with a 4-0 vicryl after subcuticular closure. • A 10-mL syringe filled with 5 mL bupivacaine is attached before inserting the implant. This helps prevent the catheter from slipping back into the pocket.
Figure 1. Augmentation mammaplasty follow-up 1 day postoperatively. On-Q pump on right breast and self-administration on left.
• At the conclusion of surgery, patency is tested by instilling bupivacaine. No flow = kinked catheter, corrected by releasing 4-0 vicryl and advancing the catheter. • Before discharge, a 30-inch sterile extension set (Abbott Laboratories, North Chicago, IL) is attached to the luer lock.
data comparing their efficacy is lacking. Further, little is known concerning the benefits of continuous flow versus intermittent bolus administration of local anesthesia. The present study was designed to compare efficacy and patient preferences with respect to administration of 0.25% bupivacaine in a commercially available pain pump using continuous infusion versus a system of patient self-administration using intermittent bolus. The location of pain and the effect of one system on the opposite breast are discussed, and current literature is reviewed.
• A 60-mL syringe (each side) filled with 40 mL bupivacaine with epinephrine is attached to the extension set for later instillation by the patient.
Methods
• Patients are given our home phone numbers if any questions arise.
A prospective, randomized (alternating side to side) study was undertaken of 41 patients who underwent subpectoral augmentation mammaplasty and received postoperative pain management between May 2002 and February 2003. Patients served as their own control. They received bupivacaine via self-administration (SA) through a syringe device to one breast and the On-Q (IFlow Corp, Lake Forest, CA) continuous infusion pump (2 mL per hour) to the other breast (Figure 1). The technique for self-administration indwelling catheters is described in Table 1. All procedures were performed by a single surgeon (PTP). Pain scores, location of pain, analgesic use, muscle relaxant use, and patient preferences were collected over a 7-day follow-up period. Written informed consent was obtained from all patients. The patients were divided into 2 groups (Table 2). Group 1 consisted of 20 patients who were permitted to
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• Syringes are placed into a fanny pack or pants pocket. Elastic vests and Ace bandages are no longer used at any time after the surgery. • Instillations done by the patient are generally done in the evening and the following morning. Patients are told to “jiggle” their breasts for 5 to 10 minutes. This helps to disperse the local anesthesia and also sets the stage for implant mobility maneuvers, in that patients get comfortable moving the implants early on.
• Total cost is less than $10.00.
Table 2. Study protocol (n = 41) Self-administration: Two groups, 0.25% bupivacaine HCl with 1:400,000 epinephrine Group 1 (n = 20): 2 doses, 20 mL per dose per breast every 6 hours, as needed Group 2 (n = 21): 4 doses, 10 mL per dose per breast every 4 hours Versus Continuous flow: On-Q System One group (n = 41): 2 mL per hour per breast
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A
B Figure 2. Patient preference results. A, Group 1 (n = 20, 20 mL per dose per breast every 6 hours as needed). B, Group 2 (n = 21, 10 mL per dose per breast every 4 hours).
bolus themselves with 20 mL of 0.25% bupivacaine HCl with 1:400,000 epinephrine (Sensorcaine; Astra Zeneca, Wilmington, DE) as needed, every 6 hours for a maximum of 2 doses. Group 2 consisted of 21 patients who were requested to instill 10 mL of 0.25% bupivacaine with 1:400,000 epinephrine every 4 hours (total 4 instillations) regardless of need (except during sleep). Results with regard to effectiveness and patient preference in both groups were assessed. All patients were requested to avoid
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any additional analgesics or narcotics for 30 to 60 minutes after self-administration in order to record an unbiased self-assessment response to the instillation of local anesthesia. All patients were seen the day after surgery and given an additional 20 mL of bupivacaine on the selfadministration side before implant mobility exercises. Three patients maintained the systems for a second day. Pain was scored (1 = no pain, 10 = worst pain) by the nurses when the patients returned to the recovery room
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and hourly thereafter until discharge. The location of the pain and the pain medications used were recorded. Before discharge, the questionnaire was explained to the patient and caregiver and written instructions were given to them. Physician and nurse home telephone numbers were provided and patients were called the evening of surgery. In group 1, patients recorded pain scores on each side in the evening before self-administration and again on both sides 30 to 60 minutes after unilateral self-administration. The same was done the following day and before the office visit. In group 2, 4 postoperative before-andafter-instillation pain scores were recorded prior to the office visit following each self-administration of local anesthesia. The office visit usually consisted of unilateral administration of bupivacaine by the nurses; before-andafter pain scores were recorded. Patients who used no instillations or only 1 instillation, and therefore had local anesthesia left over, were requested to self-administer 1 hour before the office visit to facilitate implant mobility exercises. This instillation then counted as the office visit. At the time of the first postoperative visit on the following day, patients either continued with a similar questionnaire if the catheters remained in place or were given a different questionnaire to record average pain in the afternoon, evening, and the following day if the catheters were removed. Finally, a separate questionnaire was filled out by the patients to record average pain and all medications used on days 3 though 7. The author reviewed all questionnaires.
Results Patient preference
In group 1, 10 patients preferred the continuous On-Q infusion, 9 patients preferred the self-administration bolus, and 1 patient who had no pain on either side was undecided. In group 2, 13 patients preferred the continuous On-Q infusion, 5 patients preferred self-administration and 3 patients were undecided (Figure 2). Patient preferences were further supported by an analysis of the total 24-hour raw pain scores multiplied by the number of patients. Group 1 pain scores showed little difference between the systems (group 1: SA sum = 435, On-Q sum = 437). Group 2 On-Q pain scores were lower than SA (group 2: SA sum = 802, On-Q sum = 728). The samples were too small for statistical analysis. There were no complications associated with either device.
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Contralateral pain reduction
The evaluation of pain reduction as a comparison between the 2 systems was more difficult because of the unexpected finding that after unilateral self-administration, 20 of 41 patients (42%) noted bilateral reduction of pain. The influence of the continuous flow system on the pain scores of the contralateral breast is unknown. Asymmetrical implants
Asymmetrical implants (10-35 mL difference) were placed in 12 patients, 10 of whom had a larger implant placed on the right side. Of these, 7 had the self-administration device on the side with the larger implant. The total differences in fill volume (left and right) were 170 mL on the larger self-administration side compared to 75 mL on the larger side with the On-Q device. If smaller implants tend to elicit less pain, then this discrepancy may have given some advantage to the On-Q side. Narcotic use
Of the 41 patients studied, 7 did not use any narcotics (17%); a total of 14 (34%) were narcotic- free by day 1, 19 (46%) by day 2, and 33 (80%) by day 3. Pain location
Only 1 patient had isolated breast pain. Among the others, 33 of 41 patients (80%) complained of sternal pain either associated with breast pain (26, 63%) or sternal pain only (7, 17%). Severe isolated sternal pain was associated with a poor response to local anesthesia and appeared to respond better to narcotics and/or ibuprofen. Other areas of pain included interscapular pain, and pain along the sides of the chest, armpits, and top of the breasts with or without associated breast pain.
Discussion In an earlier report by Pacik et al, 1 indwelling catheters were used for postoperative instillation of bupivacaine in 200 consecutive augmentation mammaplasty patients. It was found that 80% of the patients had considerable pain relief after instillation of 0.25% bupivacaine with 1:400,000 epinephrine. This study was initiated in December 1996, at a time when continuous flow catheters were either unavailable or not widely used. The ongoing prospective study, which is now in excess of 380 consecutive patients, was interrupted to compare the On-Q continuous flow system with intermittent bolus infusion, using 41 patients who served as their own con-
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trols. In the present study, there was little difference in group 1, which compared bolus self-administration as needed to continuous flow. Advantages of the continuous flow system are ease of use without patient participation, and maintenance of reduced pain. Patients who favored self-administration generally commented on the noticeable reduction of pain, which was not as evident on the continuous-flow side. Patients who had little or no pain in their breasts, but who had noticeable discomfort in the sternal and interscapular areas, thought that the lack of pain in the breasts was “normal” and therefore downplayed the role of the continuous flow catheters. Patients who are unwilling to spend the additional $200 for the pain pumps, or who desire to treat their own postoperative pain only as needed, have available to them an inexpensive system (less than $10) using intermittent bolus injection via 60mL syringes which, when used as needed, appeared to be as effective as continuous administration. When the present study was initiated, it seemed that the comparison of our well established system of selfadministration of bupivacaine to a continuous flow system would be a straightforward study. This turned out to not be the case: 20 of 41 patients (42%) noted bilateral reduction of pain after unilateral self-administration of bupivacaine. Most of the articles reviewed were prospective, controlled studies of continuous flow of local anesthesia versus patient-blinded studies of continuous flow of saline, in randomized patients, and all of these studies were by necessity unilateral studies. In augmentation mammaplasty, studies provide a unique opportunity in that the patient can serve as her own control; however, future studies comparing different anesthetics or different pumps in the same person will need to take into account the influence of one system on the opposite side. Asymmetrical implants introduce a variable of unknown importance. In our ongoing study, differences in pain experienced on each side are periodically noted even with symmetrical implants, and represent an additional variable that may skew controlled studies. As future studies evolve and “matched” controls are used, inaccuracies may still be created; patients may be “matched” for a variety of parameters, yet they may have considerable differences in their pain tolerance. Referred pain to the sternum and upper breast may be related to stretch of the lateral anterior thoracic nerve (lateral pectoral nerve) that supplies the deep surface of the upper sternocostal and clavicular portions of the pectoralis major muscle (RA Greengrass, MD: personal e-
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mail communication). This pain was not controlled by parasternal or sternal subcutaneous injections. Pain along the sides, base of the armpit, and armpit may be due to irritation of the fourth intercostal nerve. The cause of interscapular pain is not clear. It has been noted that when breast expanders are filled in the office, there is a certain point of expansion at which the patient complains first of shoulder pain and then interscapular pain (J. Hochberg, MD: personal e-mail communication). It is understandable that plastic surgeons have been slow to embrace the idea of indwelling catheters for augmentation mammaplasty patients, given concerns about contamination and the potential for infection. Fortunately, however, most reports demonstrate a zero infection rate. In our own ongoing study of more than 380 consecutive patients, there have been no infections. In this series, 1 patient experienced unilateral implant deflation 7 weeks postoperatively (etiology unknown) and 2 hematomas required re-operation. Three patients had kinked catheters, corrected by advancing the catheters. Six patients returned incomplete questionnaires. All available data was used. It was noted that patients had poor memories after 2 to 3 days, and by 1 week postoperatively it was impossible to gather meaningful data, which emphasized the importance of collecting prospective data. Also of importance is the review of the questionnaire at the time of the office visit to fill in incomplete responses. I have found that a review of the questionnaire helps me direct the length of time required for the indwelling catheters and helps me counsel the patient about continued pain management. Literature Review
The use of indwelling catheters to control postoperative pain and reduce the need for narcotics is becoming widely accepted in a variety of specialties. Little data on this issue are available in the plastic surgery literature. Many of the articles reviewed were from the orthopedic literature and discussed the use of continuous flow catheters as an extension of preoperative nerve blocks. As noted in an editorial by Klein,3 this technique is associated with sustained, effective postoperative analgesia; opioid sparing; improved rehabilitation, and improved patient well being with minimal side effects. Klein4 studied 40 adult patients scheduled for open rotator cuff repair, comparing a continuous flow interscalene brachial plexus block using 0.2% ropivacaine to saline in a prospective, randomized, doubleblinded, placebo-controlled study. He demonstrated a sig-
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nificant reduction in morphine consumption (P = 0.0004), and significant reduction in pain (P < 0.001) in the continuous flow group. Rawal et al,5 in a study of 60 patients scheduled for ambulatory hand surgery, compared ropivacaine to bupivacaine, using catheters to maintain an axillary plexus blockade. Reduction of pain scores was seen with both drugs. On the day of surgery, ropivacaine was noted to be more effective (P < 0.05); however, the differences were not statistically significant the following days. These authors feel that bolus analgesia, as needed, is superior to continuous infusion because not all patients have postoperative pain. Catheters have been left in the axillary plexus sheath for up to 16 days without untoward effects.6,7 Ilfeld et al,8 in a controlled study of 30 patients undergoing moderately painful, upper extremity orthopedic surgery, noted that a continuous infraclavicular nerve block with ropivacaine significantly reduced pain, and that patients had less pain with movement, used fewer oral narcotics, and had overall greater satisfaction without complications. Hoenecke,9 in 2 studies involving knee surgery, compared different flow rates of bupivacaine to controls. The 2 mL per hour flow rate showed results similar to the 5 mL per hour rate and both studies demonstrated reduced pain and reduced narcotic usage compared to controls. In the author’s experience of 500 patients, there were no toxic effects of the local anesthetic, infections related to the catheter, or wound healing problems. Other specialties have reported on the success of postoperative catheters. Pain after cesarean delivery was studied by Givens et al10 and Fredman et al.11 Givens noted significant reduction of narcotic use in the bupivacaine group, with 1 infection in this group. In Fredman’s study of 50 patients, “rescue” morphine was significantly less (P < 0.01) and pain scores generated after coughing and leg raises were significantly less (P < 0.04) in the ropivacaine group. Givens indicated that at present it is uncertain how much pain is attributable to the incision compared to uterine pain. It was his opinion that elimination of some of the superficial components of pain after cesarean delivery could modulate the perception of deeper visceral pain. Gupta et al12 left a catheter in the bed of the gallbladder after laparoscopic cholecystectomy in a controlled study of 40 patients (ropivacaine versus saline, n = 20 each) using intermittent bolus infusions of 10 mL of 0.5% ropivacaine as needed for postoperative pain. During the first 4 hours postoperatively, the ropivacaine
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group had statistically significant lower scores for deep (visceral) pain and pain during coughing. After 4 hours, pain in general was mild in intensity in both groups. Morrison et al13 noted the value of pain pumps after mastectomy in conjunction with the use of suction drains. The benefits of continuous flow catheters in colon and rectal surgery were reported by Faria14 and by Kumar.15 A report by White et al16 compared the efficacy of 0.25% and 0.5% bupivacaine to a placebo control group at a flow rate of 4 mL per hour after open heart surgery. Sternal pain was significantly improved, as was reduction of patient-controlled analgesia morphine, in the 0.5% group. No significant differences in these parameters were noted by the 0.25% bupivacaine and control groups. Time to ambulation and duration of hospital stay were lower in the 0.5% group. Benefits of continuous flow local anesthesia were reported by Vintar et al17 after inguinal hernia repair; Zimberg et al18 and Ng et al19 after elective abdominal hysterectomy; Stringer et al20 with respect to managing trochar site pain after operative laparoscopy; and Enneking et al21 after upper extremity amputation for malignancy. Bergman et al22 reported on neurologic complications of 405 consecutive, continuous axillary catheters in 368 patients. Nine complications were noted in 8 patients (2.2%), including localized infection, axillary hematoma, a retained catheter fragment requiring surgical excision, and signs and symptoms of systemic (preseizure) local anesthetic toxicity in 2 patients. The incidence of neurologic complications with continuous axillary blockade was similar to that of single-dose techniques. Liu et al,23 in a review article, summarized pertinent anatomy, technical aspects, and current evidence when available in prospective randomized trials for the indications and efficacy of continuous perineural techniques for postoperative analgesia. A variety of blocks were discussed, as well as a review of the literature. Delivery rate accuracy of 6 portable infusion pumps was studied by Ilfeld et al.24 Infusion rate accuracy differed significantly among the pumps, exhibiting flow rates ±15% of their expected rate for 18% to 100% of their infusion duration. An increase in temperature also affected pumps to differing degrees, with infusion rates increasing from 0% to 25% for each model tested. Current Protocol
Our current protocol is shown in Table 3. All augmentation mammaplasty patients are injected with a subcuta-
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neous preoperative loading dose of 20 mL of 0.25% bupivacaine with 1:400,000 epinephrine per breast. Injections are placed with a spinal needle along the lateral, central, and medial aspects of the breast and the lowered inframammary crease. At the conclusion of the procedure, a self-administration catheter or the On-Q continuous flow system is inserted to the level of the clavicle. The self-administration catheter exits laterally to attach via sterile extension tubing to 60-mL syringes and patency is tested using 5 mL of bupivacaine on each side. The On-Q catheter exits medially to connect with the opposite side and delivers 2 mL per hour per breast of 0.25% bupivacaine without epinephrine. Epinephrine is not needed because of the continuous flow of anesthetic into the dissected space. Self-administration patients are given an additional 20 mL of 0.25% bupivacaine with epinephrine per side before discharge, plus 2 doses of 20 mL per side to use at home as needed. The following day, before implant mobility exercises, an additional 20 mL of bupivacaine is instilled into the self-administration catheters, unless the patient has an unused dose left over, in which case they are asked to instill this dose 1 hour before the office visit. Pain sheets are reviewed to determine the efficacy of the various analgesics, and the results, together with the patient’s desires, will determine if the catheters are left in for a second day. In the larger study of 350 consecutive patients,2 62 patients (18%) maintained the catheters for 2 days. It appears that elastic vests and circumferential ace bandage wraps increase postoperative pain, and these have been eliminated. This was described by Tebbetts.25
Conclusion Indwelling catheters for administration of continuous flow or intermittent bolus anesthesia after augmentation mammaplasty are effective in controlling postoperative pain. Both bolus self-administration as needed and continuous flow were found to be more effective in pain control than bolus self-administration on a predetermined schedule. In addition, patient preference was almost equally divided between bolus self-administration as needed and continuous flow. Each system has advantages and both systems appear to be safe. Continuous flow maintains a steady state of pain control without patient intervention. Self-administration allows patients to have a more active role if they have pain and is an effective, low cost alternative to a commercial pain pump. When used as part of a multimodal pain management program, the infusion of a long-acting anesthetic by either method appears to be ben-
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Table 3. Current protocol Self-administration 20 mL 0.25% bupivacaine HCl 1:400,000 epinephrine each side Preoperative infiltration 40 mL Before discharge 40 mL Evening dose 40 mL Next day 40 mL Following day office visit = additional 40 mL before implant mobility exercises On-Q System Continuous flow 0.25% bupivacaine HCl without epinephrine Preoperative infiltration 40 mL 2 mL per hour per breast 96 mL Recommended allowance Each dose 225 mg (90 mL) Total 24-hour dose = 400 mg (160 mL)
eficial for postoperative pain control and also appears to result in a decrease in the length of the pain cycle and the use of narcotics for pain control. These conclusions are supported by a review of the literature. I am grateful to Craig E. Nelson, PhD, for his help with the database; to Kay Werner, RN, for her long-term help with this study; to Gloria Smith, for relentlessly pursuing completed questionnaires; and to Janet Lynn, for her expertise in database maintenance and manuscript preparation. I would also like to thank the I-Flow Corporation for providing pumps to use in this study, and Alan Dine for his help in setting up the comparisons. References 1. Pacik PT, Werner C, Jackson N, Lobsitz C. Pain control in augmentation mammaplasty: the use of indwelling catheters in 200 consecutive patients. Plast Reconstr Surg 2003;111:2090-2096. 2. Pacik PT, Werner C. Follow-up: pain control in augmentation mammaplasty: the use of indwelling catheters in 350 consecutive patients. Plast Reconstr Surg (in press). 3. Klein SM. Beyond the hospital: continuous peripheral nerve blocks at home. Anesthesiology 2002;96:1283-1285. 4. Klein SM, Grant SA, Greengrass RA, Nielsen KC, Speer KC, White W, et al. Interscalene brachial plexus block with a continuous catheter insertion system and a disposable infusion pump. Anesth Analg 2000;91: 1473-1478. 5. Rawal N, Ailvin R, Axelsson K, Hallen J, Ekback G, Ohlsson T, et al. Patient controlled regional anesthesia (PCRA) at home. Controlled comparison between bupivacaine and ropivacaine brachial plexus analgesia. Anesthesiology 2002;96:1290-1296.
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6. Ang ET, Lassale B, Goldfarb G. Continuous axillary brachial plexus block—a clinical and anatomical study. Anesth Analg 1984;63:680-684. 7. Sarma VJ. Long-term continuous axillary plexus blockade using 0.25% bupivacaine. Acta Anesthesiology Scand 1990;34:511-513. 8. Ilfeld BM, Morey TE, Enneking FK. Continuous infraclavicular brachial plexus block for postoperative pain control at home. A randomized, doubleblinded, placebo-controlled study. Anesthesiology 2002;96:1297-1304.
18. Zimberg SE, Davila G, Seiler J, Neimark M. On-Q pain management system in elective abdominal hysterectomy. Am J Obstet and Gynecol 2002;99:4(suppl). 19. Ng A, Swami A, Smith G, Davidson AC, Emembolu J. The analgesic effects of intraperitoneal and incisional bupivacaine with epinephrine after total abdominal hysterectomy. Anesth Analg 2002;95:158-162.
9. Hoenecke HR. Continuous local anesthetic infiltration. Orthopedic Technol Rev 2002;2:1-4.
20. Stringer NH, Rodino KL, Edwards M, Kumari N. On-Q system for managing trochar site pain after operative laparoscopy. J Am Assoc Gynecol Laparoscop 2000;7:552-555.
10. Givens VA, Lipscomb GH, Meyer NL. A randomized trial of postoperative wound irrigation with local anesthetic for pain after cesarean delivery. Am J Obstet Gynecol 2002;186:1188-1191.
21. Enneking FK, Scarborough MT, Radson EA. Local anesthetic infusion through nerve sheath catheters for analgesia following upper extremity amputation. Regional Anesth 1997;22:351-356.
11. Fredman B, Shapiro A, Zohar E, Feldman E, Shorer S, Rawal N, et al. The analgesic efficacy of patient-controlled ropivacaine instillation after cesarean delivery. Anesth Analg 2000;91:1436-1440.
22. Bergman BD, Hebl JR, Kent J, Horlocker TT. Neurologic complications of 405 consecutive continuous axillary catheters. Anesth Analg 2003;96: 247-252.
12. Gupta A, Thorn SE, Axelsson K, Larsson LG, Agren G, Holmstrom B, et al. Postoperative pain relief using intermittent injections of 0.5% ropivacaine through a catheter after laparoscopic cholecystectomy. Anesth Analg 2002;95:450-456.
23. Liu SS, Salinas FV. Continuous plexus and peripheral nerve blocks for postoperative analgesia. Anesth Analg 2003;96:263-273.
13. Morrison Jr JE, Jacobs VR. Reduction or elimination of postoperative pain medication after mastectomy through use of a temporarily placed local anesthetic pump vs control group. Zentralbl Gynakol 2003;125:17-22. 14. Faria TA. The On-Q pain management system in the control of postoperative pain in colon and rectal surgery [abstract]. United European Gastroenterology Week. Amsterdam, October 6-10, 2001. 15. Kumar S. Continuous postoperative analgesia in anorectal surgery— hemorrhordectomy. Novel Concepts Presented at the American Society of Colorectal Surgeons Annual Meeting, June 3-8, 2002.
24. Ilfeld BM, Morey TE, Enneking FK. The delivery rate accuracy of portable infusion pumps used for continuous regional analgesia. Anesth Analg 2002;95:1331-1336. 25. Tebbetts JB. Achieving a predictable 24-hour return to normal activities after breast augmentation: Part I. Refining practices by using motion and time study principles. Plast Reconstr Surg 2002;109:273-290. Accepted for publication August 20, 2004. Presented in part at the Annual Meeting of the American Society of Plastic Surgeons, San Diego, California, October 29, 2003. During the study, Dr. Pacik was unaware that I-Flow is a publicly traded company. At present, he maintains shares in this company.
16. White PF, Rawal S, Latham P, Markowitz S, Issioui T, Chi L, et al. Use of a continuous local anesthetic infusion for pain management after median sternotomy. Anesth Analg 2003;99:918-923.
Reprint requests: Peter T. Pacik, MD, 57 Bay Street, Manchester, NH 03104.
17. Vintar N, Pozlep G, Rawal N, Godec M, Rakovec S. Incisional self-administration of bupivacaine or ropivacaine provides effective analgesia after inguinal hernia repair. Can J Anesth 2002;49:481-486.
doi:10.1016/j.asj.2004.09.003
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Copyright © 2004 by The American Society for Aesthetic Plastic Surgery, Inc. 1090-820X/$30.00
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Pain Management in Augmentation Mammaplasty: A Randomized, Comparative Study of the Use of a Continuous Infusion Versus Self-Administration Intermittent Bolus of a Local Anesthetic Peter T. Pacik, MD Dr. Pacik is in private practice in Manchester, NH.
Background: Indwelling catheters for pain control after augmentation mammaplasty appear to be safe and effective. However, little is known regarding the comparison of continuous flow to intermittent bolus anesthetics. Objective: A prospective, randomized study was developed to compare these 2 systems. Methods: Forty-one patients were divided into 2 groups. All patients used the On-Q (I-Flow Corp, Lake Forest, CA) continuous infusion pump system (2 mL per hour) in 1 breast. Group 1 consisted of 20 patients who, in the opposite breast, were permitted to bolus themselves with 20 mL of 0.25% bupivacaine HCl with 1:400,000 epinephrine (Sensorcaine; Astra Zeneca, Wilmington, DE) as needed, every 6 hours for a maximum of 2 doses. Group 2 consisted of 21 patients who were requested to instill 10 mL of 0.25% bupivacaine with 1:400,000 epinephrine every 4 hours (total 4 instillations) regardless of need (except during sleep). Results with regard to effectiveness and patient preference in both groups were assessed. All patients were asked to avoid any additional analgesics or narcotics for 30 to 60 minutes after self-administration in order to record an unbiased self-assessment response to the instillation of local anesthesia. All patients were seen the day after surgery and given an additional 20 mL of bupivacaine on the self-administration side before implant mobility exercises. Results: In group 1, 10 patients preferred the continuous On-Q infusion, 9 patients preferred the self-administration bolus, and 1 patient who had no pain on either side was undecided. Among patients in this group, 24-hour pain scores were similar. In group 2, 13 patients preferred the continuous On-Q infusion, 5 patients preferred self-administration, and 3 patients were undecided. Pain scores in group 2 were lower for On-Q. An unexpected finding was that after unilateral self-administration, 20 of 41 patients (42%) noted bilateral reduction of pain. By day 3, 33 of 41 patients (80%) used no narcotics. There were no complications associated with either device. Conclusions: After augmentation mammaplasty, both indwelling catheters using continuous flow and intermittent bolus anesthesia as needed are effective in controlling postoperative pain. Continuous flow maintains a steady state of pain control without patient intervention. Self-administration allows patients to have a more active role if they have pain and is an effective low-cost alternative to a commercial pain pump. These conclusions are supported by a review of the literature and by our own experience with more than 380 consecutive patients. (Aesthetic Surg J 2004;24:523-530.)
I
ndwelling catheters are used to introduce local anesthesia in order to control postoperative pain in a variety of surgical specialties. However, the use of this type of pain control in augmentation mammaplasty procedures is in its infancy. Little is known as to whether intermittent bolus anesthesia or continuous flow is more effective. Patients undergoing submuscular augmentation mammaplasty may experience significant postoperative pain and discomfort. The use of narcotics and muscle
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relaxants has not offered complete relief. In response to this problem, we conducted an initial trial of 200 patients, over a 5-year period (1996-2001), treated with periodic instillations of bupivacaine through indwelling catheters placed in the subpectoral pocket. We determined that local anesthetics delivered in this manner are both safe and effective.1,2 At the time the study was initiated, continuous flow systems were generally unavailable. A number of continuous flow “pain pumps” are now on the market, but
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Table 1. Indwelling catheter technique • The needle of a scalp vein catheter (Exel scalp vein set, Exelint International, Los Angeles, CA) is cut off and discarded. • The full length of the catheter (usually 8-Fr) is placed first, posterior to the implant. • The cut tip is placed superiorly. The luer lock end exits at the lateral margin of incision, held with a 4-0 vicryl after subcuticular closure. • A 10-mL syringe filled with 5 mL bupivacaine is attached before inserting the implant. This helps prevent the catheter from slipping back into the pocket.
Figure 1. Augmentation mammaplasty follow-up 1 day postoperatively. On-Q pump on right breast and self-administration on left.
• At the conclusion of surgery, patency is tested by instilling bupivacaine. No flow = kinked catheter, corrected by releasing 4-0 vicryl and advancing the catheter. • Before discharge, a 30-inch sterile extension set (Abbott Laboratories, North Chicago, IL) is attached to the luer lock.
data comparing their efficacy is lacking. Further, little is known concerning the benefits of continuous flow versus intermittent bolus administration of local anesthesia. The present study was designed to compare efficacy and patient preferences with respect to administration of 0.25% bupivacaine in a commercially available pain pump using continuous infusion versus a system of patient self-administration using intermittent bolus. The location of pain and the effect of one system on the opposite breast are discussed, and current literature is reviewed.
• A 60-mL syringe (each side) filled with 40 mL bupivacaine with epinephrine is attached to the extension set for later instillation by the patient.
Methods
• Patients are given our home phone numbers if any questions arise.
A prospective, randomized (alternating side to side) study was undertaken of 41 patients who underwent subpectoral augmentation mammaplasty and received postoperative pain management between May 2002 and February 2003. Patients served as their own control. They received bupivacaine via self-administration (SA) through a syringe device to one breast and the On-Q (IFlow Corp, Lake Forest, CA) continuous infusion pump (2 mL per hour) to the other breast (Figure 1). The technique for self-administration indwelling catheters is described in Table 1. All procedures were performed by a single surgeon (PTP). Pain scores, location of pain, analgesic use, muscle relaxant use, and patient preferences were collected over a 7-day follow-up period. Written informed consent was obtained from all patients. The patients were divided into 2 groups (Table 2). Group 1 consisted of 20 patients who were permitted to
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• Syringes are placed into a fanny pack or pants pocket. Elastic vests and Ace bandages are no longer used at any time after the surgery. • Instillations done by the patient are generally done in the evening and the following morning. Patients are told to “jiggle” their breasts for 5 to 10 minutes. This helps to disperse the local anesthesia and also sets the stage for implant mobility maneuvers, in that patients get comfortable moving the implants early on.
• Total cost is less than $10.00.
Table 2. Study protocol (n = 41) Self-administration: Two groups, 0.25% bupivacaine HCl with 1:400,000 epinephrine Group 1 (n = 20): 2 doses, 20 mL per dose per breast every 6 hours, as needed Group 2 (n = 21): 4 doses, 10 mL per dose per breast every 4 hours Versus Continuous flow: On-Q System One group (n = 41): 2 mL per hour per breast
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A
B Figure 2. Patient preference results. A, Group 1 (n = 20, 20 mL per dose per breast every 6 hours as needed). B, Group 2 (n = 21, 10 mL per dose per breast every 4 hours).
bolus themselves with 20 mL of 0.25% bupivacaine HCl with 1:400,000 epinephrine (Sensorcaine; Astra Zeneca, Wilmington, DE) as needed, every 6 hours for a maximum of 2 doses. Group 2 consisted of 21 patients who were requested to instill 10 mL of 0.25% bupivacaine with 1:400,000 epinephrine every 4 hours (total 4 instillations) regardless of need (except during sleep). Results with regard to effectiveness and patient preference in both groups were assessed. All patients were requested to avoid
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any additional analgesics or narcotics for 30 to 60 minutes after self-administration in order to record an unbiased self-assessment response to the instillation of local anesthesia. All patients were seen the day after surgery and given an additional 20 mL of bupivacaine on the selfadministration side before implant mobility exercises. Three patients maintained the systems for a second day. Pain was scored (1 = no pain, 10 = worst pain) by the nurses when the patients returned to the recovery room
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and hourly thereafter until discharge. The location of the pain and the pain medications used were recorded. Before discharge, the questionnaire was explained to the patient and caregiver and written instructions were given to them. Physician and nurse home telephone numbers were provided and patients were called the evening of surgery. In group 1, patients recorded pain scores on each side in the evening before self-administration and again on both sides 30 to 60 minutes after unilateral self-administration. The same was done the following day and before the office visit. In group 2, 4 postoperative before-andafter-instillation pain scores were recorded prior to the office visit following each self-administration of local anesthesia. The office visit usually consisted of unilateral administration of bupivacaine by the nurses; before-andafter pain scores were recorded. Patients who used no instillations or only 1 instillation, and therefore had local anesthesia left over, were requested to self-administer 1 hour before the office visit to facilitate implant mobility exercises. This instillation then counted as the office visit. At the time of the first postoperative visit on the following day, patients either continued with a similar questionnaire if the catheters remained in place or were given a different questionnaire to record average pain in the afternoon, evening, and the following day if the catheters were removed. Finally, a separate questionnaire was filled out by the patients to record average pain and all medications used on days 3 though 7. The author reviewed all questionnaires.
Results Patient preference
In group 1, 10 patients preferred the continuous On-Q infusion, 9 patients preferred the self-administration bolus, and 1 patient who had no pain on either side was undecided. In group 2, 13 patients preferred the continuous On-Q infusion, 5 patients preferred self-administration and 3 patients were undecided (Figure 2). Patient preferences were further supported by an analysis of the total 24-hour raw pain scores multiplied by the number of patients. Group 1 pain scores showed little difference between the systems (group 1: SA sum = 435, On-Q sum = 437). Group 2 On-Q pain scores were lower than SA (group 2: SA sum = 802, On-Q sum = 728). The samples were too small for statistical analysis. There were no complications associated with either device.
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Contralateral pain reduction
The evaluation of pain reduction as a comparison between the 2 systems was more difficult because of the unexpected finding that after unilateral self-administration, 20 of 41 patients (42%) noted bilateral reduction of pain. The influence of the continuous flow system on the pain scores of the contralateral breast is unknown. Asymmetrical implants
Asymmetrical implants (10-35 mL difference) were placed in 12 patients, 10 of whom had a larger implant placed on the right side. Of these, 7 had the self-administration device on the side with the larger implant. The total differences in fill volume (left and right) were 170 mL on the larger self-administration side compared to 75 mL on the larger side with the On-Q device. If smaller implants tend to elicit less pain, then this discrepancy may have given some advantage to the On-Q side. Narcotic use
Of the 41 patients studied, 7 did not use any narcotics (17%); a total of 14 (34%) were narcotic- free by day 1, 19 (46%) by day 2, and 33 (80%) by day 3. Pain location
Only 1 patient had isolated breast pain. Among the others, 33 of 41 patients (80%) complained of sternal pain either associated with breast pain (26, 63%) or sternal pain only (7, 17%). Severe isolated sternal pain was associated with a poor response to local anesthesia and appeared to respond better to narcotics and/or ibuprofen. Other areas of pain included interscapular pain, and pain along the sides of the chest, armpits, and top of the breasts with or without associated breast pain.
Discussion In an earlier report by Pacik et al, 1 indwelling catheters were used for postoperative instillation of bupivacaine in 200 consecutive augmentation mammaplasty patients. It was found that 80% of the patients had considerable pain relief after instillation of 0.25% bupivacaine with 1:400,000 epinephrine. This study was initiated in December 1996, at a time when continuous flow catheters were either unavailable or not widely used. The ongoing prospective study, which is now in excess of 380 consecutive patients, was interrupted to compare the On-Q continuous flow system with intermittent bolus infusion, using 41 patients who served as their own con-
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trols. In the present study, there was little difference in group 1, which compared bolus self-administration as needed to continuous flow. Advantages of the continuous flow system are ease of use without patient participation, and maintenance of reduced pain. Patients who favored self-administration generally commented on the noticeable reduction of pain, which was not as evident on the continuous-flow side. Patients who had little or no pain in their breasts, but who had noticeable discomfort in the sternal and interscapular areas, thought that the lack of pain in the breasts was “normal” and therefore downplayed the role of the continuous flow catheters. Patients who are unwilling to spend the additional $200 for the pain pumps, or who desire to treat their own postoperative pain only as needed, have available to them an inexpensive system (less than $10) using intermittent bolus injection via 60mL syringes which, when used as needed, appeared to be as effective as continuous administration. When the present study was initiated, it seemed that the comparison of our well established system of selfadministration of bupivacaine to a continuous flow system would be a straightforward study. This turned out to not be the case: 20 of 41 patients (42%) noted bilateral reduction of pain after unilateral self-administration of bupivacaine. Most of the articles reviewed were prospective, controlled studies of continuous flow of local anesthesia versus patient-blinded studies of continuous flow of saline, in randomized patients, and all of these studies were by necessity unilateral studies. In augmentation mammaplasty, studies provide a unique opportunity in that the patient can serve as her own control; however, future studies comparing different anesthetics or different pumps in the same person will need to take into account the influence of one system on the opposite side. Asymmetrical implants introduce a variable of unknown importance. In our ongoing study, differences in pain experienced on each side are periodically noted even with symmetrical implants, and represent an additional variable that may skew controlled studies. As future studies evolve and “matched” controls are used, inaccuracies may still be created; patients may be “matched” for a variety of parameters, yet they may have considerable differences in their pain tolerance. Referred pain to the sternum and upper breast may be related to stretch of the lateral anterior thoracic nerve (lateral pectoral nerve) that supplies the deep surface of the upper sternocostal and clavicular portions of the pectoralis major muscle (RA Greengrass, MD: personal e-
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mail communication). This pain was not controlled by parasternal or sternal subcutaneous injections. Pain along the sides, base of the armpit, and armpit may be due to irritation of the fourth intercostal nerve. The cause of interscapular pain is not clear. It has been noted that when breast expanders are filled in the office, there is a certain point of expansion at which the patient complains first of shoulder pain and then interscapular pain (J. Hochberg, MD: personal e-mail communication). It is understandable that plastic surgeons have been slow to embrace the idea of indwelling catheters for augmentation mammaplasty patients, given concerns about contamination and the potential for infection. Fortunately, however, most reports demonstrate a zero infection rate. In our own ongoing study of more than 380 consecutive patients, there have been no infections. In this series, 1 patient experienced unilateral implant deflation 7 weeks postoperatively (etiology unknown) and 2 hematomas required re-operation. Three patients had kinked catheters, corrected by advancing the catheters. Six patients returned incomplete questionnaires. All available data was used. It was noted that patients had poor memories after 2 to 3 days, and by 1 week postoperatively it was impossible to gather meaningful data, which emphasized the importance of collecting prospective data. Also of importance is the review of the questionnaire at the time of the office visit to fill in incomplete responses. I have found that a review of the questionnaire helps me direct the length of time required for the indwelling catheters and helps me counsel the patient about continued pain management. Literature Review
The use of indwelling catheters to control postoperative pain and reduce the need for narcotics is becoming widely accepted in a variety of specialties. Little data on this issue are available in the plastic surgery literature. Many of the articles reviewed were from the orthopedic literature and discussed the use of continuous flow catheters as an extension of preoperative nerve blocks. As noted in an editorial by Klein,3 this technique is associated with sustained, effective postoperative analgesia; opioid sparing; improved rehabilitation, and improved patient well being with minimal side effects. Klein4 studied 40 adult patients scheduled for open rotator cuff repair, comparing a continuous flow interscalene brachial plexus block using 0.2% ropivacaine to saline in a prospective, randomized, doubleblinded, placebo-controlled study. He demonstrated a sig-
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nificant reduction in morphine consumption (P = 0.0004), and significant reduction in pain (P < 0.001) in the continuous flow group. Rawal et al,5 in a study of 60 patients scheduled for ambulatory hand surgery, compared ropivacaine to bupivacaine, using catheters to maintain an axillary plexus blockade. Reduction of pain scores was seen with both drugs. On the day of surgery, ropivacaine was noted to be more effective (P < 0.05); however, the differences were not statistically significant the following days. These authors feel that bolus analgesia, as needed, is superior to continuous infusion because not all patients have postoperative pain. Catheters have been left in the axillary plexus sheath for up to 16 days without untoward effects.6,7 Ilfeld et al,8 in a controlled study of 30 patients undergoing moderately painful, upper extremity orthopedic surgery, noted that a continuous infraclavicular nerve block with ropivacaine significantly reduced pain, and that patients had less pain with movement, used fewer oral narcotics, and had overall greater satisfaction without complications. Hoenecke,9 in 2 studies involving knee surgery, compared different flow rates of bupivacaine to controls. The 2 mL per hour flow rate showed results similar to the 5 mL per hour rate and both studies demonstrated reduced pain and reduced narcotic usage compared to controls. In the author’s experience of 500 patients, there were no toxic effects of the local anesthetic, infections related to the catheter, or wound healing problems. Other specialties have reported on the success of postoperative catheters. Pain after cesarean delivery was studied by Givens et al10 and Fredman et al.11 Givens noted significant reduction of narcotic use in the bupivacaine group, with 1 infection in this group. In Fredman’s study of 50 patients, “rescue” morphine was significantly less (P < 0.01) and pain scores generated after coughing and leg raises were significantly less (P < 0.04) in the ropivacaine group. Givens indicated that at present it is uncertain how much pain is attributable to the incision compared to uterine pain. It was his opinion that elimination of some of the superficial components of pain after cesarean delivery could modulate the perception of deeper visceral pain. Gupta et al12 left a catheter in the bed of the gallbladder after laparoscopic cholecystectomy in a controlled study of 40 patients (ropivacaine versus saline, n = 20 each) using intermittent bolus infusions of 10 mL of 0.5% ropivacaine as needed for postoperative pain. During the first 4 hours postoperatively, the ropivacaine
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group had statistically significant lower scores for deep (visceral) pain and pain during coughing. After 4 hours, pain in general was mild in intensity in both groups. Morrison et al13 noted the value of pain pumps after mastectomy in conjunction with the use of suction drains. The benefits of continuous flow catheters in colon and rectal surgery were reported by Faria14 and by Kumar.15 A report by White et al16 compared the efficacy of 0.25% and 0.5% bupivacaine to a placebo control group at a flow rate of 4 mL per hour after open heart surgery. Sternal pain was significantly improved, as was reduction of patient-controlled analgesia morphine, in the 0.5% group. No significant differences in these parameters were noted by the 0.25% bupivacaine and control groups. Time to ambulation and duration of hospital stay were lower in the 0.5% group. Benefits of continuous flow local anesthesia were reported by Vintar et al17 after inguinal hernia repair; Zimberg et al18 and Ng et al19 after elective abdominal hysterectomy; Stringer et al20 with respect to managing trochar site pain after operative laparoscopy; and Enneking et al21 after upper extremity amputation for malignancy. Bergman et al22 reported on neurologic complications of 405 consecutive, continuous axillary catheters in 368 patients. Nine complications were noted in 8 patients (2.2%), including localized infection, axillary hematoma, a retained catheter fragment requiring surgical excision, and signs and symptoms of systemic (preseizure) local anesthetic toxicity in 2 patients. The incidence of neurologic complications with continuous axillary blockade was similar to that of single-dose techniques. Liu et al,23 in a review article, summarized pertinent anatomy, technical aspects, and current evidence when available in prospective randomized trials for the indications and efficacy of continuous perineural techniques for postoperative analgesia. A variety of blocks were discussed, as well as a review of the literature. Delivery rate accuracy of 6 portable infusion pumps was studied by Ilfeld et al.24 Infusion rate accuracy differed significantly among the pumps, exhibiting flow rates ±15% of their expected rate for 18% to 100% of their infusion duration. An increase in temperature also affected pumps to differing degrees, with infusion rates increasing from 0% to 25% for each model tested. Current Protocol
Our current protocol is shown in Table 3. All augmentation mammaplasty patients are injected with a subcuta-
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neous preoperative loading dose of 20 mL of 0.25% bupivacaine with 1:400,000 epinephrine per breast. Injections are placed with a spinal needle along the lateral, central, and medial aspects of the breast and the lowered inframammary crease. At the conclusion of the procedure, a self-administration catheter or the On-Q continuous flow system is inserted to the level of the clavicle. The self-administration catheter exits laterally to attach via sterile extension tubing to 60-mL syringes and patency is tested using 5 mL of bupivacaine on each side. The On-Q catheter exits medially to connect with the opposite side and delivers 2 mL per hour per breast of 0.25% bupivacaine without epinephrine. Epinephrine is not needed because of the continuous flow of anesthetic into the dissected space. Self-administration patients are given an additional 20 mL of 0.25% bupivacaine with epinephrine per side before discharge, plus 2 doses of 20 mL per side to use at home as needed. The following day, before implant mobility exercises, an additional 20 mL of bupivacaine is instilled into the self-administration catheters, unless the patient has an unused dose left over, in which case they are asked to instill this dose 1 hour before the office visit. Pain sheets are reviewed to determine the efficacy of the various analgesics, and the results, together with the patient’s desires, will determine if the catheters are left in for a second day. In the larger study of 350 consecutive patients,2 62 patients (18%) maintained the catheters for 2 days. It appears that elastic vests and circumferential ace bandage wraps increase postoperative pain, and these have been eliminated. This was described by Tebbetts.25
Conclusion Indwelling catheters for administration of continuous flow or intermittent bolus anesthesia after augmentation mammaplasty are effective in controlling postoperative pain. Both bolus self-administration as needed and continuous flow were found to be more effective in pain control than bolus self-administration on a predetermined schedule. In addition, patient preference was almost equally divided between bolus self-administration as needed and continuous flow. Each system has advantages and both systems appear to be safe. Continuous flow maintains a steady state of pain control without patient intervention. Self-administration allows patients to have a more active role if they have pain and is an effective, low cost alternative to a commercial pain pump. When used as part of a multimodal pain management program, the infusion of a long-acting anesthetic by either method appears to be ben-
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Table 3. Current protocol Self-administration 20 mL 0.25% bupivacaine HCl 1:400,000 epinephrine each side Preoperative infiltration 40 mL Before discharge 40 mL Evening dose 40 mL Next day 40 mL Following day office visit = additional 40 mL before implant mobility exercises On-Q System Continuous flow 0.25% bupivacaine HCl without epinephrine Preoperative infiltration 40 mL 2 mL per hour per breast 96 mL Recommended allowance Each dose 225 mg (90 mL) Total 24-hour dose = 400 mg (160 mL)
eficial for postoperative pain control and also appears to result in a decrease in the length of the pain cycle and the use of narcotics for pain control. These conclusions are supported by a review of the literature. I am grateful to Craig E. Nelson, PhD, for his help with the database; to Kay Werner, RN, for her long-term help with this study; to Gloria Smith, for relentlessly pursuing completed questionnaires; and to Janet Lynn, for her expertise in database maintenance and manuscript preparation. I would also like to thank the I-Flow Corporation for providing pumps to use in this study, and Alan Dine for his help in setting up the comparisons. References 1. Pacik PT, Werner C, Jackson N, Lobsitz C. Pain control in augmentation mammaplasty: the use of indwelling catheters in 200 consecutive patients. Plast Reconstr Surg 2003;111:2090-2096. 2. Pacik PT, Werner C. Follow-up: pain control in augmentation mammaplasty: the use of indwelling catheters in 350 consecutive patients. Plast Reconstr Surg (in press). 3. Klein SM. Beyond the hospital: continuous peripheral nerve blocks at home. Anesthesiology 2002;96:1283-1285. 4. Klein SM, Grant SA, Greengrass RA, Nielsen KC, Speer KC, White W, et al. Interscalene brachial plexus block with a continuous catheter insertion system and a disposable infusion pump. Anesth Analg 2000;91: 1473-1478. 5. Rawal N, Ailvin R, Axelsson K, Hallen J, Ekback G, Ohlsson T, et al. Patient controlled regional anesthesia (PCRA) at home. Controlled comparison between bupivacaine and ropivacaine brachial plexus analgesia. Anesthesiology 2002;96:1290-1296.
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6. Ang ET, Lassale B, Goldfarb G. Continuous axillary brachial plexus block—a clinical and anatomical study. Anesth Analg 1984;63:680-684. 7. Sarma VJ. Long-term continuous axillary plexus blockade using 0.25% bupivacaine. Acta Anesthesiology Scand 1990;34:511-513. 8. Ilfeld BM, Morey TE, Enneking FK. Continuous infraclavicular brachial plexus block for postoperative pain control at home. A randomized, doubleblinded, placebo-controlled study. Anesthesiology 2002;96:1297-1304.
18. Zimberg SE, Davila G, Seiler J, Neimark M. On-Q pain management system in elective abdominal hysterectomy. Am J Obstet and Gynecol 2002;99:4(suppl). 19. Ng A, Swami A, Smith G, Davidson AC, Emembolu J. The analgesic effects of intraperitoneal and incisional bupivacaine with epinephrine after total abdominal hysterectomy. Anesth Analg 2002;95:158-162.
9. Hoenecke HR. Continuous local anesthetic infiltration. Orthopedic Technol Rev 2002;2:1-4.
20. Stringer NH, Rodino KL, Edwards M, Kumari N. On-Q system for managing trochar site pain after operative laparoscopy. J Am Assoc Gynecol Laparoscop 2000;7:552-555.
10. Givens VA, Lipscomb GH, Meyer NL. A randomized trial of postoperative wound irrigation with local anesthetic for pain after cesarean delivery. Am J Obstet Gynecol 2002;186:1188-1191.
21. Enneking FK, Scarborough MT, Radson EA. Local anesthetic infusion through nerve sheath catheters for analgesia following upper extremity amputation. Regional Anesth 1997;22:351-356.
11. Fredman B, Shapiro A, Zohar E, Feldman E, Shorer S, Rawal N, et al. The analgesic efficacy of patient-controlled ropivacaine instillation after cesarean delivery. Anesth Analg 2000;91:1436-1440.
22. Bergman BD, Hebl JR, Kent J, Horlocker TT. Neurologic complications of 405 consecutive continuous axillary catheters. Anesth Analg 2003;96: 247-252.
12. Gupta A, Thorn SE, Axelsson K, Larsson LG, Agren G, Holmstrom B, et al. Postoperative pain relief using intermittent injections of 0.5% ropivacaine through a catheter after laparoscopic cholecystectomy. Anesth Analg 2002;95:450-456.
23. Liu SS, Salinas FV. Continuous plexus and peripheral nerve blocks for postoperative analgesia. Anesth Analg 2003;96:263-273.
13. Morrison Jr JE, Jacobs VR. Reduction or elimination of postoperative pain medication after mastectomy through use of a temporarily placed local anesthetic pump vs control group. Zentralbl Gynakol 2003;125:17-22. 14. Faria TA. The On-Q pain management system in the control of postoperative pain in colon and rectal surgery [abstract]. United European Gastroenterology Week. Amsterdam, October 6-10, 2001. 15. Kumar S. Continuous postoperative analgesia in anorectal surgery— hemorrhordectomy. Novel Concepts Presented at the American Society of Colorectal Surgeons Annual Meeting, June 3-8, 2002.
24. Ilfeld BM, Morey TE, Enneking FK. The delivery rate accuracy of portable infusion pumps used for continuous regional analgesia. Anesth Analg 2002;95:1331-1336. 25. Tebbetts JB. Achieving a predictable 24-hour return to normal activities after breast augmentation: Part I. Refining practices by using motion and time study principles. Plast Reconstr Surg 2002;109:273-290. Accepted for publication August 20, 2004. Presented in part at the Annual Meeting of the American Society of Plastic Surgeons, San Diego, California, October 29, 2003. During the study, Dr. Pacik was unaware that I-Flow is a publicly traded company. At present, he maintains shares in this company.
16. White PF, Rawal S, Latham P, Markowitz S, Issioui T, Chi L, et al. Use of a continuous local anesthetic infusion for pain management after median sternotomy. Anesth Analg 2003;99:918-923.
Reprint requests: Peter T. Pacik, MD, 57 Bay Street, Manchester, NH 03104.
17. Vintar N, Pozlep G, Rawal N, Godec M, Rakovec S. Incisional self-administration of bupivacaine or ropivacaine provides effective analgesia after inguinal hernia repair. Can J Anesth 2002;49:481-486.
doi:10.1016/j.asj.2004.09.003
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